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i '��� <br /> SAN JOAQUIN 'LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE:; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (20) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> V THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San. Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name IFICIMAD _gEga32LIA10 Phone _q(09 (933ALC�Pe / <br /> Address 33 E EL7r/ER. P,D 6- City AfAL-AAPO <br /> Contr'actor's Name �IWGW IA/t"Z4- -PIplt.t4&1� �p License 03370,Mhone"7$F 337, <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/Y RECONDITION AL / /_7_/ DESTRUCTION / _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other E P_ W <br /> . Lt! <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /Dp PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL 40-49 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF' WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing _/��, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Y Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout - OF <br /> i! <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: Z <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ; H.P. T <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: - Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AND A FINA N PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 <br /> 677 _ 2M <br />